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HomeMy WebLinkAboutPermit Plumbing 1998-12-29 . BACKFLOI/ PREVENTION DEVICE PERMIT APPLICATIO:i CITY OF SPRINGFIELD BUILDING SAFETY DIVISION 225 FIFTH STREET SPRINGFIE::,D OR 97477 JFFICE: 726-3759 INSPECTIC:l LINE: 726..3769 ------------------------------------7------- ------------------ ~. - --------- - .. ----- " JOB LOCATION: 2 S-6 4- J"T j1():l~<J,2 TAX LOT ji: 210D .' ASSESSORS MAP B: Ol/NER: 5.17#-;;'af-,'~/./ O~/~'h/ . ../ I'" ADDRESS: .,/7 t1 g I? Y .f oz; CITY: 5jl?j-/M /0' rC/)I? / d gt7~~ PHONE B:7Y7-'-.76":?Y ZIP: }??Y?7 STATE: c;1)- BACKFLOII PERMIT IS $15.00 + $,75 (STATE SURClIARGE) + $,45 (AD! eN, FEE) = $16,20 CONTRA,CTOlV #/I7r--&'Y' /36a:/ );,6'r:./d/r./~S " '., ""t:::/vnotv- ADDRESS: '7/'/ V .t:,1JCw rules ~~~:~gon law reo.uJJlONE B: ./ 2- 6'; ,5'? 2-.7 -.:' ""Cation C .~ vy uy tI1e 0 You to -- . CITY: 5dr-/fi e? ,t:::./ ' '1'" /,d!! OAR 95;:>_n,,~n~Elf'l'A'rBsEl.!u/"~ Utilit'( ZIP: l7~ 7 '7 17 7 ' vytlu. You .;:J1 OJl)J:o .~ltOr1h .>. CONSTRUCTION CONTRACTORS REGJ:Sll'~'li~~~!>tajtf 1a6~:pf52-o01~SXPIRES: #-s- t1'Z? nUmber for th ter. (Note: the t ,"01 rUles by . e or!!!lQn~' . e ephone BY SIGNING THIS PERMITI APPLICATI~~t~ iM~_ fl/~b'PtiI1eBti,(t,l,l IN:: ?ECTION ONCE TilE BACKFLOII PREVENTION DEVICE HAS BEEN INSTALLE 'kfifj44J3 VISYtJLE ':JR INSPECTION (726-3769), I ALSO STATE THAT ALL INFORMATION ON TIlIS PERMIT. APPLICATION ~eB.\<. CORRECT . ~' . Ell" ,\-Ic ~O\\C '" S\-If>-I..I.. E'ISJlt'\ I'EB.~I\ \'2> \,<01 1\-11S I'c~~ \.l\'<ocB. ,\-lIS \,<cO rOB. \-IOI'-I1.cO ~f>-\'<OO J' f>-\.ll E\'<CcO O. I'- IS 2- - it J'- ,7 e 1.J;:)~1-JI ,1m 1 o~ [)Pol ' f>-\'<'{ '\0" . ~~~/./~~ SIGNA-fURl:. " . FOR OFFICE USE ---------.-----------------1- --7------------------ -----------.. -------- --- - ------ DATE OF /;PPLICATION: I ~/ ).1'/ q( j . JO;; #:..3.$Js j(~\ RECEIPT I':_{)~ 1.<1~' ISSUED B'l:_ ,111 . fh..uc..---- TOTAL AMOUNT COLLECTED: T I U '2J}) -------_.._----------------------------'":"---------------------- - ----------_.. ------